Tadalafil (Adcirca, Alyq) 

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:
  • Indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO [World Health Organization] Group 1) to improve exercise ability
Patients must meet the following criteria for the indication(s) above:
  • Adcirca®, Alyq™, Revatio® (tablets):
    • Patient has a diagnosis of Pulmonary Arterial Hypertension (WHO Group 1) with class II, III, or IV symptoms confirmed by a specialist (e.g., cardiologist, pulmonologist) (medical record documentation required)
  • Revatio® (suspension):
    • Patient has a diagnosis of Pulmonary Arterial Hypertension (WHO Group 1) with class II, III, or IV symptoms confirmed by a specialist (e.g., cardiologist, pulmonologist) (medical record documentation required), AND
    • Patient cannot swallow or has difficulty swallowing tablet formulation, OR
    • Patient requires administration of a dose that cannot be obtained with generic sildenafil 20 mg tablets
The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P&T Committee:
  • Peripheral vasoconstriction
  • Patients taking nitrates
  • Erectile dysfunction (ED)
  • All non-FDA approved uses not listed in the approved indications
Dosing:
  • Adcirca®: 40 mg daily
  • Alyq™: 40 mg daily
  • Revatio®: 20 mg three times a day
Approval:
  • One year

Last review date: August 10, 2020